A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Administer intravenous pain medication.

Draw blood for a complete blood cell (CBC) count.

Insert an indwelling urinary catheter.

Inspect the mouth for signs of inhalation injuries.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This choice is incorrect because administering intravenous pain medication is not the priority action for a client who has sustained partial-thickness burns. Pain medication may be indicated for pain relief and comfort, but it does not address the potential life-threatening complications of burns such as shock, infection, or respiratory distress.

Choice B Reason: This choice is incorrect because drawing blood for a CBC count is not the priority action for a client who has sustained partial-thickness burns. A CBC count may be useful to monitor the hematological status and detect any signs of infection or anemia, but it does not address the immediate needs of the client

Choice C Reason: This choice is incorrect because inserting an indwelling urinary catheter is not the priority action for a client who has sustained partial-thickness burns. A urinary catheter may be necessary to measure the urine output and assess the renal function and ﬂuid balance, but it does not address the most urgent problem of the client.

Choice D Reason: This choice is correct because inspecting the mouth for signs of inhalation injuries is the priority action for a client who has sustained partial-thickness burns. Inhalation injuries are caused by inhaling hot air, smoke, or toxic gases that damage the airway and lungs. They can cause airway obstruction, bronchospasm, pulmonary edema, or respiratory failure. Therefore, the nurse should inspect the mouth for signs such as soot, singed nasal hairs, burns on the lips or tongue, hoarseness, stridor, or wheezes. The nurse should also monitor the oxygen saturation and arterial blood gases to assess the oxygenation and ventilation status of the client.

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Correct Answer is D

Explanation

Choice A Reason: Observing for cerebrospinal ﬂuid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice B Reason: Checking the oximeter is also important, but not the first action that the nurse should take. The oximeter measures the oxygen saturation of the blood, which reﬂects the adequacy of gas exchange in the lungs. The nurse should maintain the oxygen saturation above 90%, and administer supplemental oxygen as prescribed.

However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice C Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inﬂammation, or damage to the hypothalamus, which can aﬀect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice D Reason: Monitoring for manifestations of increased intracranial pressure is the first action that the nurse should take. Increased intracranial pressure can result from bleeding, swelling, or ﬂuid accumulation in the brain, which can compress and damage brain tissue and blood vessels. The nurse should assess for signs and symptoms of increased intracranial pressure, such as headache, nausea, vomiting, altered level of consciousness, pupillary changes, or Cushing's triad (bradycardia, hypertension, and irregular respirations). The nurse should also intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. Monitoring for manifestations of increased intracranial pressure is essential to prevent further brain injury and preserve neurological function.

A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.26, HCO3 24, PaCO2 46 C. pH 7.26, HCO3 14, PaCO2 30 D. pH 7.49, HCO3 30, PaCO2 40

Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect because it indicates respiratory alkalosis, not AKI. Respiratory alkalosis is a condition in which the lungs eliminate too much carbon dioxide (CO2) from the blood, resulting in a low level of CO2 (PaCO2) and a high level of pH. A normal PaCO2 range is 35 to 45 mm Hg, and a normal pH range is 7.35 to 7.45, so a value of 30 mm Hg and 7.49 indicate respiratory alkalosis.

Choice B Reason: This choice is incorrect because it indicates respiratory acidosis, not AKI. Respiratory acidosis is a condition in which the lungs cannot eliminate enough CO2 from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A value of 46 mm Hg and 7.26 indicate respiratory acidosis.

Choice C Reason: This choice is correct because it indicates metabolic acidosis, which is a common complication of AKI. Metabolic acidosis is a condition in which the body produces too much acid or loses too much base, resulting in a low level of bicarbonate (HCO3) and a low level of pH. A normal HCO3 range is 22 to 26 mEq/L, so a value of 14 mEq/L indicates metabolic acidosis. The low PaCO2 value (30 mm Hg) is due to the respiratory compensation mechanism that tries to restore the acid-base balance by increasing the ventilation and eliminating more CO2.

Choice D Reason: This choice is incorrect because it indicates metabolic alkalosis, not AKI. Metabolic alkalosis is a condition in which the body loses too much acid or gains too much base, resulting in a high level of bicarbonate (HCO3) and a high level of pH. A value of 30 mEq/L and 7.49 indicate metabolic alkalosis.

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